Calculating, manipulative, possibly violent yet also frequently charming and alluring, the person with antisocial personality disorder presents a unique clinical challenge: even the most seasoned clinician may not make the diagnosis until the patient has conned even the psychiatrist.
Treatment is possible—in some patients, under some conditions—but even then the clinician should approach the encounter with only guarded optimism and a sober sense of what is achievable, said Glen O. Gabbard, M.D., at APA’s 2003 Institute on Psychiatric Services in Boston.
In an overview of the diagnosis and treatment of antisocial personality disorder (APD), Gabbard painted a clinical portrait of the antisocial personality to match the chilling depictions of con artists and predators found in literature—individuals who may be psychologically, genetically, and even physiologically unique.
“These people are potentially dangerous,” he said. “It is very important to distinguish between who is completely untreatable and who might be treatable under certain circumstances. In certain settings, there appears to be some possibility of treatment for a subgroup of these patients.”
Yet so masterful are the machinations of the antisocial personality—so practiced are the habits of self-interested calculation and manipulation—that clinicians can easily be hoodwinked.
“Nobody is such a good clinician that he or she can never get conned,” Gabbard said. “You can have all the training in the world and still get taken.”
Gabbard is the Brown Foundation Chair of Psychoanalysis and a professor of psychiatry at Baylor College of Medicine in Houston. He is also director of the Baylor Psychiatry Clinic and training and supervising analyst at the Houston-Galveston Psychoanalytic Institute.
He also worked for six years in the prison system—a fertile ground, he said, for studying personality disorders. According to one study, an estimated 75 percent of prisoners—according to one study—met criteria for antisocial personality disorder, Gabbard said.
But he noted that the DSM-IV diagnostic criteria for antisocial personality have been modified slightly to correct an overemphasis on criminal history in earlier editions. And Gabbard cautioned that many people with antisocial personality are out and about among us.
“There are antisocial physicians, clergy, and attorneys,” he said. “It is very important for us to have a wide enough view of this to know that all of these people are not in prison.”
Gabbard outlined the current diagnostic criteria for antisocial personality disorder (see box) and surveyed the evolution of thinking about the disorder. He noted that the term “psychopath”—prominent in the middle of the 20th century, later replaced by the term “sociopath”—has returned in usage to describe an especially refractory subgroup of people with APD.
He cited the work of Robert Hare, Ph.D., of the University of British Columbia, who has defined a narrow set of criteria for recognizing the psychopathic antisocial personality. Such an individual would be characterized by antisocial behavior in adolescence and adulthood along with the following: superficiality, grandiosity, manipulation, lack of remorse, lack of empathy, impulsiveness, poor behavior control, and disavowal of responsibility.
Gabbard questioned the finding of “lack of empathy” among such individuals, noting that in many cases they possess enormous powers of empathic discernment—albeit for the purposes of self-aggrandizement.
He described an antisocial individual who got himself admitted to a hospital on the pretext that he was suffering severe depression in the aftermath of a car crash in which his wife and children had been killed.
The patient movingly described how much he loved his wife to the female resident psychiatrist, who was moved to sympathy and even admiration for the man. At one point, when the resident was taking a history and asked about sexual problems, the man stopped her and said, “My wife and I didn’t have sex; we made love.”
Later, when the man disappeared after swindling money from fellow patients by selling nonexistent land in Florida, the resident recalled, “He knew exactly what would appeal to me.”
Gabbard said, “The resident felt [the patient] had tuned in perfectly to her and to what would draw her in to being conned.”
Underscoring the peculiar “otherness” of the antisocial personality, Gabbard warned that a clinical pitfall in assessing and treating it is the assumption of “psychological complexity.”
“You think, ‘These people are basically like I am—they have a superego, and they think about other people’s feelings and have conflicts about things and experience guilt.’ We think they are like us, when they are not like us.”
Some research appears to support the view that people with antisocial personality may be not only psychologically but also genetically and physiologically distinct.
He cited a study in which Adrian Raine, D.Phil., and colleagues in the department of psychology at the University of Southern California studied thrill-seeking behavior in criminal activity by measuring autonomic arousal (as assessed by heart rate and skin conductance).
In a retrospective study, Raine and colleagues studied 101 50-year-olds, 17 of whom had antisocial behavior as adolescents but had stopped criminal behavior. Seventeen others with antisocial behavior as teens continued criminal activity into adulthood.
Those who desisted from criminal behavior had the higher electrodermal and cardiovascular arousal, while the group that continued the criminal behavior had low autonomic arousal.
“What this suggests is that individuals predisposed to adult crime because of juvenile delinquency may be protected from committing crimes as adults by high levels of autonomic arousal,” Gabbard said.
In psychoanalytic terms, he said, this suggests a physiologic marker for the presence or absence of a superego. “If you are anxious about doing something wrong or afraid of hurting someone, getting caught, or being the subject of parental disapproval, you would have a higher autonomic response,” he said. “Somebody who is physiologically different probably does not have that kind of anxiety in response to doing something criminal.”
Gabbard cited related research findings that implicate both environmental and genetic factors in the development of APD—especially the MAOA gene, which encodes the enzyme that metabolizes norepinephrine, serotonin, and dopamine.
In a study published last year in Science, Caspi and colleagues at the Institute of Psychiatry at King’s College, London, studied a large sample of males in Dunedin, New Zealand, from birth to adulthood to determine why some children who are maltreated grow up to develop antisocial behavior, whereas others do not.
They found that children who had low MAOA activity and were severely maltreated as children had elevated antisocial scores, while those who had high MAOA activity did not have high antisocial scores even if they had experienced childhood maltreatment.
“The authors concluded that a functional polymorphism in the MAOA genotype moderates the impact of early childhood maltreatment on the development of antisocial behavior,” Gabbard said.
For all the caution that individuals with APD should inspire, the condition may be treatable in the presence of certain conditions and characteristics, Gabbard said.
These include depression, anxiety, the ability to form a therapeutic alliance, and some evidence of a superego. Any of these is likely to indicate that the individual is not of the psychopathic subgroup of APD.
Even then, optimism should be guarded, and excessive expectations should be avoided. He outlined some fundamentals of engaging the antisocial personality:
• The clinician must be stable, persistent, and incorruptible and should be alert to the likelihood of legal problems and legal entanglements.
• The patient’s minimalization of antisocial behavior should be confronted in the here and now, and an attempt should be made to connect actions to internal states.
• Axis I conditions should be identified, as should situational factors that worsen behaviors.
• Countertransference must be monitored to avoid acting out on the part of the clinician.
The factors that do not favor therapy—probably indicative of a psychopathic subtype—include a history of sadistic violence resulting in death or injury to others, a total absence of remorse, a historical incapacity to form emotional attachments, and a level of intelligence that is either in the range of mildly mentally retarded or very superior.
Finally, the chill of dread—a fear of predation experienced by even seasoned clinicians—can be a sure sign of the presence of a malevolent, antisocial personality.
“I try to teach my residents to trust their gut instinct,” Gabbard said. “If you think you are not safe, and you feel the hair on the back of your neck standing up, trust that instinct.” ▪